3 PN Mental

1. A nurse is collecting data from a client who has dementia and whose family expresses concern about hisincreasing “memory problems.” Which of the following findingsshould the nurse identify as the priority? Answer: The client sometimes wandersfrom the house 2. A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goalsshould the nurse recommend be included in the plan? Answer: The client will discussfeelings that cause hostility 3. A nurse is planning to collect data from a group of clients. The nurse should expect threat which of the following clients is likely to exhibit speech pattern alterations? Answer: A client who has schizophrenia 4. A nurse in a community center is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? Answer: Impulsive behavior 5. A nurse isreinforcing teaching with a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods containing tyramine can cause which of the following adverse reactions wit this medication? Answer: Hypertensive crisis 6. A nurse is caring for a client who reports recent amphetamine use. Which of the following manifestations should the nurse expect? Answer: Paranoia 7. A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider’srecommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client’s decision? Answer: Autonomy 8. A nurse isreinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? Answer: Have you considered participating in a sport to help control your aggression 9. A nurse on an inpatient mental health unit is supervising a group of clients in the unit’s dayroom. The nurse failsto respond to the escalating, aggressive behavior of a client eventually becomes violent and injures another client. For which of the following isthe nurse liable? Answer: Negligence 10. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findingsshould the nurse withhold the client’s medications and notify the provider? Answer: WBC count 11. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? Answer: The client who is experiencing command hallucinations 12. A nurse isreinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? Answer: You should listen to music when you feel stress 13. A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following action should the nurse take? Answer: Administer oxygen to the client 14. A nurse is caring for a client who has psychiatric symptom disorder. Which of the following actions should the nurse take? Answer: Encourage the client to examine how hisillness behavior affects hisfamily 15. A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? Answer: Have you had any thoughts of harming yourself 16. A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? Answer: Stand in front of the client when speaking 17. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? Answer: Naloxone 18. A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findingsshould the nurse identify as manifestations of bulimia nervosa? Answer: -Tooth erosion -Hand calluses -Hypokalemia 19.. nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Answer: Pupillary dilation 20. A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse includes? Answer: Dietitian 21. A nurse is assisting with discharge planning for a client who needs a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client’s discharge plan? Answer: Social worker 22. A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few momentslater,the client cheerfully states, “Now,here is my favorite social worker!” The nurse should identify the client is using which of the following defense mechanisms? Answer: Reaction formation 23. A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? Answer: A client who has borderline personality disorder and is pacing restlessly 24. A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information? Answer: I will probably feel irritable within 24 hours of my last cigarette 25. A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explainsthe therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts isthe nurse demonstrating? Answer: Veracity 26. A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Answer: Promote The development of problem-solving skills 27. A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? Answer: Feeling of hopelessness 28. A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? Answer: Administer haloperidol to a client who has schizophrenia and is yelling at other clients. 29.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? Answer: Offer liquid supplements to the client 30. A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and beginsthrowing objects at staff and other clients. After calling for assistance. Which of the following actions should the nurse take next? Answer: Tell the client calmly to sit down 31. A nurse caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse reports to the charge nurse? Answer: A client who is manic has been pacing the unit for several hours 32. A nurse is collecting data from a client who istaking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider? Answer: Bleeding gums 33. A nurse is attempting to resolve an ethical dilemma that involves a client’s medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? Answer: Determine the benefits and consequences of respecting the client’s medical Decisions 34. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? Answer: I will snap a rubber band on my wrist when I feel anxious about riding in a car 35. A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? Answer: A nurse does not notify the provider of a change in condition for a client who has schizophrenia 36. A nurse in a provider’s office is collecting data from an older adult client whose adult child reports that she “seems confused and can’t seem to remember much.”Which of the following findings should lead the nurse to suspect delirium? Answer: The client’s level of consciousness changes during the interview 37. A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She statesto the nurse,”I am so angry that my doctor didn’t take better care of me and my baby.” Which of the following responses should the nurse make? Answer: It is important to share what you are feeling, even if it is anger 38. A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? Answer: Establish and explain consequences for the client’s behavior 39. A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? Answer: Encourage the client to develop a safety plan 40. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client’s use of this substance? Answer: Hypertension 41. A nurse in a mental health facility is caring for a client who has dementia. The client’s agitation is increasing. Which of the following actions should the nurse take first? Answer: Offer diversionary activities 42. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? Answer: Determine the client’sintentions 43. A nurse isreinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? Answer: Do not drive until your reaction to the medication is determined 44. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, “My youngest child died 6 months ago while serving in the military.” Which of the following responses should the nurse make? Answer: -This must be very difficult time for you -Your child’s death must be a terrible loss -Tell me something you remember about your child 45. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client? Answer: Have the client’sfavorite snacks available at all times. 46. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? Answer: Projects blame onto others 47. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client? Answer: When you raise your voice, it makes me feel uncomfortable and unsafe.” 48. A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client’s confidentiality? Answer: The nurse places the client’s diagnosis on the white board in the client’s room 49. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findingsisreferred to as a negative symptom of schizophrenia? Answer: Apathy 50. A nurse in a long-term care center is caring for an adult client who has Alzheimer’s disease and whose partner died several years ago. The client appears upset and aslsthe nurse when his partner will visit again. The nurse states,”It seems like you are feeling lonely. Let’s take a walk outside and talk.’ Which of the following communication strategies is the nurse using? Answer: Validation therapy 51. A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statementsshould the nurse include in the teaching? Answer:” The voices you have been hearing should decrease.” 52. A nurse isreinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statementsshould the nurse identify as an indication that the client understands the information? Answer: “I should expect some improvement of my symptoms in about 10 days 53. A nurse is caring for a client who has major depressive disorder(MDD). The client states.”I have nothing to live for anymore. I just can’t go on.” Which of the following responses should the nurse make? Answer: Are you thinking about ending your life 54. A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist.”I know more than you do about the people in this room!” The nurse should identify that which of the following findings is the likely explanation for the client’s behavior? Answer: Hypomania 54. A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statementsshould the nurse make to gather information about the client’s ability to think abstractly? Answer: How is an orange similar to an apple